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Processing Text in Medical Databases

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Computer Medical Databases

Part of the book series: Health Informatics ((HI))

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Abstract

In the 1950s the clinical data in medical records of patients in the United States were mostly recorded in a natural, English-language, textual form. This was commonly done by physicians when recording their notes on paper sheets for a patient’s medical history and physical examination, for reporting their interpretations of x-ray images and electrocardiograms, and for their dictated descriptions of medical and surgical procedures. Such patients’ data were generally recorded by health-care professionals as hand-written notes, or as dictated reports that were then transcribed and typed on paper sheets, that were all collated in paper-based charts; and these patients’ medical charts were then stored on shelves in the medical record room. The process of manually retrieving data from patients’ paper-based medical charts was always cumbersome and time consuming. An additional frequent problem was when a patient was seeing more than one physician on the same day in the same medical facility; then that patient’s paper-based chart was often left in the first doctor’s office, and therefore was not available to the other physicians who then had to see the patient without having access to any recorded prior patient’s information. Pratt (1974) observed that the data a medical professional recorded and collected during the care of a patient was largely in a non-numeric form, and in the United States was formulated almost exclusively in English language. He noted that a word, a phrase, or a sentence in this language was generally understood when spoken or read; and the marks of punctuation and the order of the presentation of words in a sentence represented quasi-formal structures that could be analyzed for content according to common rules for: (a) the recognition and validation of the string of language data that was a matter of morphology and syntax; (b) the recognition and the registration of each datum and of its meaning that was a matter of semantics; and (c) the mapping of the recognized, defined, syntactical and semantic elements into a data structure reflected the informational content of the original language data string, and (d) that these processes required definition and interpretation of the information by the user.

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Collen, M.F. (2012). Processing Text in Medical Databases. In: Computer Medical Databases. Health Informatics. Springer, London. https://doi.org/10.1007/978-0-85729-962-8_3

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